Current neonatal seizure classification and approach to the newborn with seizure

Neonates are at an increased risk of seizures due to their immature brains and high risk of injury. Most neonatal seizures are provoked seizures (triggered by an acute illness or brain injury). Etiologies include hypoxic-ischemic encephalopathy, stroke, hemorrhage, infections, cortical malformations, metabolic diseases, and genetic disorders. With increasing use of bedside electroencephalographic monitoring, electrographic seizures without clinical correlation are being diagnosed more frequently. In the 2021 updated classification of the International League Against Epilepsy, abnormal clinical movements require electrographic activity for the diagnosis of a seizure. In neonates, seizures have a focal onset and are further classified according to their dominant clinical feature. Seizures can be motor, nonmotor, or sequential. All neonatal units should use evidence-based protocols to expedite the evaluation and treatment of neonatal seizures. Electroencephalograms should confirm seizure control. In neonates who do not respond to conventional antiseizure treatment, pyridoxine-dependent seizures should be ruled out.